=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285057935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY HEART CARE OF SAN ANTONIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2014
-----------------------------------------------------
Last Update Date | 10/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3903 WISEMAN BLVD STE 114
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-558-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 WEST FWY STE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-423-4400
-----------------------------------------------------
Fax | 817-423-8080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL GRATCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-423-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------